What is Public Health?

Recently, I’ve been thinking a lot about what people mean by ‘Public Health’.  This is mostly in light of going to the Public Health England annual conference a couple of weeks ago.

(As I write about this, I’m aware that I haven’t read or written as much about public health as many people, and I’m probably making some pretty basic arguments and missing some crucial points.  Even so, I think it’s helpful to have this discussion and spark some debate.  And the points I’m making are as much about the politics and practicalities of doing public health work, which I’d suggest I’m perfectly capable of commenting on, having worked in a local authority for 5 years.  Let me know your thoughts in the comments section.)

There are many potential public health issues on the horizon, from dementia and cardiovascular disease, type 2 diabetes and so on, to childhood obesity and alcohol misuse.  But the epidemiological data is astonishingly clear (echoing the alcohol harm paradox that I’ve mentioned before): these diseases and ailments are, above all, correlated with socioeconomic status.

Slide taken from Susan Jebb's presentation at the PHE Conference, available here.

Now the response of some people I’ve mentioned this to (notably not part of the public health community, and not on the left politically) has been, on childhood obesity, to lament that parenting skills just aren’t distributed equally across society.

But the response of the public health community would be to argue that it’s environmental factors and ‘choice architecture’ that structure the choices of parents and children in an unhealthy direction.

And the soft sociologists amongst you might add that class is not just about wealth and income, but culture, and so particular patterns of behaviour are transmitted that may or may not have been positive adaptations in the past, but are now potentially ‘maladaptive’ (to use a word that makes me hugely uncomfortable).

But however we look at it, there’s no doubt that housing, local amenities, education, employment opportunities, diet, and so on are all affected by who our parents are and where they live.  They are associated with locality and socio-economic background – or class, to put it bluntly.  And all those factors influence our health in the long term.

So therefore, one ‘public health’ argument runs, public health needs to be about changing the way housing, local amenities, education, employment and so on are provided.  If the job of public health professionals is to influence health inequalities – as the Coalition Government stated quite plainly – then it has to be about wider socio-economic inequalities.

This where those on the right politically, or those who are more libertarian, start to suggest that public health these days is more about political campaigning than direct health interventions.

And there’s some truth to that.  Gerard Hastings isn’t just opposed to marketing for alcohol; he’s opposed to marketing for all consumables.  The ‘Future Public Health’ (framed as a successor to ‘the new public health’) is all about saving the planet for future generations.

And indeed saving the planet was the topic of the keynote address at the PHE conference.  Of course there are health issues associated with climate change – it will affect where malaria and other diseases are prevalent, and it will cause migration that will affect disease transmission.  But if the issue is preventing (or reducing) climate change, is this a ‘public health issue’?  What is it that PHE or local public health teams can or should be doing on this?

There is a case to be made that climate change is an extreme example, which was really included at the conference as a bit of background and scene setting as an interesting talk before dinner.  And not all public health professionals or academics are (thankfully) like Gerard Hastings.  Indeed, Duncan Selbie is a great example of a political pragmatist – although this does frustrate many of his professional colleagues.

But the issue doesn’t have to be so huge as climate change for the point to still apply.  If housing is a public health issue, what is the public health intervention?  We know what ‘good’ housing looks like – and if there’s any debate about this, it’s likely to be amongst architects, town planners and engineers rather than people with a master’s degree in public health.

Are public health professionals well placed to argue about what ‘works’ in relation to employment strategies, local economic growth, or education policy?  I’m not sure they are – and local and central government, not to mention the private and third sectors, have plenty of able individuals already well qualified to lead on these issues.

So what is the public health contribution?  Well let’s think about the classic example of the Broad Street pump.  The reason cholera spread in Soho was primarily the poor quality of housing and drainage.  This was particularly bad in this area of London because the people were much poorer.  Richer areas had much better and more hygienic facilities.  So the health of the public was improved by better housing and could possibly have been improved earlier by a more equal distribution of wealth and resources.

But that required a political solution in terms of housing and social policy, as well as the simple macro-economic trend of increasing wealth and income.  But I’d argue the public health intervention is about the water supply and sewerage.

This is, in a way, tinkering at the edges: it’s a safe bet there will continue to be more diseases, even now, and that they will hit the poorest hardest.  That might not always be true, but as I say, it’s a pretty safe bet when we look at Ebola and other outbreaks.

So there is a public health point to be made that if you want to avoid these, certain improvements in housing and so forth would be beneficial, but the public health contribution is the evidence and advice to the politicians and officials who actually determine and implement housing policy.

In fact, that’s even the case in relation to improving the water supply.  It’s not the public health department who would necessarily enact something new, it would be the water board or its modern equivalent.

But the public health contribution, in all these cases, is to focus attention on the health of the public and how this might be affected by wider factors.  It has a role in contributing to the debate.

Take the example of alcohol guidelines.  There was much debate about these, but the key point is that they offer guidance to people who can then make their own decisions about how much alcohol to drink, if any.  The guidelines – perfectly justifiably – only refer to health risks.  You’d have to factor in your own thoughts about taste, intoxication, sociability and so on.

And this, rather than being a failing of the guidelines, is actually a strength.  As soon as public health somehow becomes about wider flourishing – with that worrying word ‘wellbeing’ – it is in the domain of ethics and politics.  And as Katharina Kieslich reminded the PHE conference, fair-minded people will not all agree on the priorities of any department or organisation, even in public health.  Despite the attempts of philosophers through the ages, we haven’t agreed what universal human aspirations and aims should be.  Wellbeing does not look the same for everyone, and is not as easily defined as disability-adjusted life years, which can only be a partial measure of happiness, fulfilment or wellbeing.

Yet there is this tendency for the domain of ‘health’ to expand and include various wider value judgements.  This is to some extent unavoidable, given the blurred boundaries between structure and agency, and the spectrum from choice to coercion.  And we should be more open about these grey areas.

Part of the reason that wellbeing seems like an apolitical area is that politics has been emptied of these fundamental philosophical, ethical debates.  In taking forward agendas clearly underpinned by certain ideological and ethical assumptions, successive governments from Thatcher to Cameron have sought to suggest that they are only introducing ‘efficiency’, and managing the machinery of the state more ‘effectively’ than their opponents.  If politics is simply the domain of securing economic prosperity and opportunity, while managing the neutral state apparatus effectively, then other areas – such as health and wellbeing – can reasonably be understood as being outside of politics.

So once the discussion of ethics is removed from politics, it becomes harder to see where ‘health’ ends and ‘politics’ starts.  Of course this isn’t a clear dividing line, and drawing it anywhere it arbitrary, but my fear at the moment is that it is not drawn at all, and that makes it difficult to identify what domain and responsibilities belong to ‘public health’ professionals at all.  Is it everything or nothing?  I’m certainly not an expert in everything, and no-one wants to be told they have a remit for nothing.  I think public health would flourish best with a smaller scope, but more clearly and carefully defined knowledge and responsibilities.  So before we celebrate what PHE does, it might be worth coming back to that question: ‘what is public health?’